CIRCUMCISION PROCEDURE

This index contains information about the practical
aspects of male circumcision, including:

how it is performed;

cost and reimbursement;

factors that may influence the decision;

cost-benefit analyses.

Introduction

Male neonatal circumcision is a radical invasive non-therapeutic
procedure, that removes and destroys a body part having
important physiological functions. Rosemary Romberg's classic
book, "Circumcision: the Painful Dilemma," is probably the
best reference. It shows a circumcision procedure illustrated
step-by-step with photographs and drawings (p. 162ff.)

There are illustrations of the circumcision procedure in
Edward Wallerstein's classic, "Circumcision: An American
Health Fallacy", with a discussion starting on page 204.
These pictures have been reproduced in other places,
including Jim Bigelow's book "The Joy of Uncircumcising", and
"Say No to Circumcision: 40 Compelling Reasons" by Thomas J
Ritter MD and George Denniston MD (both from Hourglass, PO
Box 171, Aptos CA 95001).

Other known devices for infant circumcision are: The Ross
circumcision ring (similar to Plastibell, but made of metal);
the Yellen clamp (looks like a woodworking C-clamp, and works
similarly to the Gomco); the Sheldon clamp
("..looks like a nail clipper on steroids..."). Some
circumcisions are done with a scalpel by a freehand method.
Anaesthesia is rarely used, and the pain is intense with all
of these methods (see the section on Pain).

The Mogen clamp
reportedly is favored by Jewish mohels because it is
said to use the traditional method of ritual circumcision. It
is also claimed to be "faster and less painful" by those who
advocate its use.

If you would like to read more about the surgical risks of
circumcision, the books of Wallerstein, and particularly
Romberg (mentioned above) are very helpful. Both of these are
unfortunately out of print, but should be available in a good
University library. See also Complications.

Articles

Circumcision Instruments

Gomco clampPatient Care
Magazine 1978; March 15:82-85.
[CIRP Note: The following reference dicusses the use of
anesthesia with the Gomco clamp circumcision. CIRP cautions
that the anesthesia used reduces but does not
eliminate pain.]

Reimbursement and Costs

The Reimbursement
Advisor gives advice to medical doctors on how to make
claims for reimbursement9
while the Survey of Fees
and Practices, reports a survey of the charges for a
circumcision by obstetricians from around the United
States.10 Mansfield reports
on the additional cost of the hospital stay for
circumcision.11Mansfield et
al. estimate that in hospital circumcisions result
in increased hospital charges for services of $234 million to
$527 million in 1990-91. Van
Howe reported the cost of a post neonatal circumcision to
be $3009 to $3241 per case.12Bollinger
reports data from HCIA-Sachs.15 HCIA-Sachs reports that the
total cost of an in-hospital non-therapeutic neonatal
circumcision in the United States has risen from $1154 in
1992 to $1869 in 1999, an increase of 62%. The total cost of
all in hospital neonatal circumcisions in the United States
is reported to be $2.1 billion in 1999. Wayne points out that
circumcision fails to meet the HCFA requirements for
reimbursement so may be fraudulent.14

Cost-Utility Analyses

Cadman et al. (1984) studied the benefits and costs
of neonatal circumcision. They concluded that the benefit
(alleged prevention of penile cancer) was insufficient to
justify the cost, so public health insurance programs should
not cover neonatal circumcision.16 Lawler et al.17 (1991) and Ganiats et
al.18 (1991) independently
concluded that the health effect of circumcision was
essentially neutral, that they could not medically justify
non-therapeutic neonatal circumcision, and that other factors
must be used to support a decision to circumcise an infant.
Lawler et al. and Ganiats et al., however,
overlooked certain adverse consequences that have now come to
the forefront. Chessare (1992) reported that non-circumcision
has the highest medical-utility.19 A more recent study by Van Howe
(2004) concludes that circumcision has an adverse effect on
health, is not good health policy, and that it cannot be
justified financially or medically.20

Factors Affecting the Circumcision Decision

The following journal articles contain information about
the factors that affect the circumcision decision. Hawa Patel
(1966) may have been the first to formally study the reasons
parents give for making the decision. 21 He found that the decisions
are usually based on misinformation or medical myths.22 Daksha A.
Patel (1982) reported low levels of physician
information.22 He recommended establishment
of educational programs.22 Taylor (1983) reported the
factors associated with circumcision are a circumcised older
brother, and prenatal health care delivered by an
obstetrician. Factors associated with no circumcision are the
fact that this male is the first born, prenatal health care
by a general practitioner, and maternal age of less than
20.23 Metcalf's study (1983) in
Salt Lake City found that the three most popular reasons for
circumcision were hygiene, social custom, and a circumcised
father.24
He also reported that one fourth of the mothers could not
remember after six months why they had their son
circumcised.24 Enzenauer (1986) found that
videotaped counseling is much more successful than oral
counseling in reducing the incidence of circumcision.25 Brown &
Brown (1987) report that social reasons, including a
circumcised father, are the most important reasons that
parents choose circumcision.26 Parental education will have
little effect according to this study.26 Tiemstra (1999) reported that
conditions have not improved much in the fifteen years since
earlier studies.27 Tiemstra studied the timing
of the parental decision about circumcision. He found that
parents tend to make up their mind before they have received
circumcision counseling.27 He believes that counseling
about circumcision should begin at first patient
contact.27 This is much earlier than is
commonly practiced in the United States.27

Adult Circumcision

Procedure

The following article illustrates the adult circumcision
procedure. It is a radical, invasive, traumatic procedure
with a long painful recovery time. It destroys the
physiological functions of the prepuce; it is the most
expensive treatment option; and it is the one procedure still
promoted by many American doctors for almost any penile
problem, even though newer treatment modalities are
available. For information on newer effective, conservative,
non-invasive, non-traumatic treatment options, see Conservative Treatment of Penile
Problems.